Provider First Line Business Practice Location Address:
4170 FAIRMOUNT AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-280-3322
Provider Business Practice Location Address Fax Number:
619-563-8888
Provider Enumeration Date:
12/21/2017